Karavadra et al.

BMC Pregnancy and Childbirth (2020) 20:600

https://doi.org/10.1186/s12884-020-03283-2

RESEARCH ARTICLE Open Access

Women’s perceptions of COVID-19 and

their healthcare experiences: a qualitative
thematic analysis of a national survey of
pregnant women in the United Kingdom
Babu Karavadra* , Andrea Stockl, Edward Prosser-Snelling, Paul Simpson and Edward Morris

Abstract
Background: The aim of this national survey was to explore pregnant women’s perceptions of COVID-19 and their
healthcare experiences.
Methods: Through patient and public involvement, a questionnaire was developed and advertised via the BBC
website, Twitter and other online media during May 2020. The findings were analysed by qualitative thematic
analysis. Women who are currently pregnant, or who have delivered during the COVID-19 pandemic were invited
to partake in a national online survey.
Results: One thousand four hundred fifty-one participants replied to the online questionnaire. Participants provided
significant insight into the perceived barriers to seeking healthcare during this pandemic. These include ‘not
wanting to bother anyone’, ‘lack of wider support from allied healthcare workers’ and the influence of the media.
Other concerns included the use of virtual clinics antenatally and their acceptability to patients, the presence of
birthing partners, and the way in which information is communicated about rapidly changing and evolving
services. The influence of the media has also had a significant impact on the way women perceive hospital care in
light of COVID-19 and for some, this has shaped whether they would seek help.
Conclusions: This is the first ever reported study in the United Kingdom to explore pregnant women’s perceptions
of COVID-19 and their subsequent healthcare experiences. It has also provided insight into perceived barriers into
seeking care as well as maternal concerns antenatally, intrapartum and postpartum.
Keywords: COVID-19, Corona virus, Pregnancy, Impact, Survey

Background a national ‘lockdown’ was declared in the United Kingdom

The impact of the COVID − 19 pandemic has been un-
imaginable and has resulted in a significant number of
deaths throughout the world [1]. In the United Kingdom,
hospitals have had to drastically change the way in which
they deliver their services, and in many instances, suspend
certain elements of care. During the COVID-19 pandemic,
* Correspondence: b.karavadra@hotmail.co.uk
Norfolk & Norwich University Hospital, Colney Lane, Norwich NR47UY, UK
and as a result, all non-essential travel and contact with
other individuals outside a person’s home environment
was banned. Significant changes were also implanted in
hospital and these included, social distancing measures,
postponement of non-essential surgery and major changes
in the way primary and secondary care services were deliv-
ered. In maternity care, many antenatal contacts occurred
virtually, restrictions were imposed on birthing partner
presence and clinicians has to use suitable personal

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Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600
protective equipment (PPE) as appropriate. At the time of
writing this paper, the current number of deaths related to
coronavirus in the United Kingdom is 46,706 (Gov.UK).
The changes in the delivery of maternity care in the
United Kingdom and the impact of these changes on
pregnant women and their birthing partners are not
known. Maternity care is very unique, and it simply can-
not stop due to the acute nature of the specialty. At
present, no studies have been conducted to explore
women’s views on the impact of COVID-19 on their
pregnancy and medical and/or midwifery care. There-
fore, the objective of our online study is to explore preg-
nant women’s’ perceptions of COVID-19 and their
healthcare experiences. It is hoped that the findings will
be used to ensure women are receiving holistic care that
is tailored to their specific needs during this pandemic.
The Royal College of Obstetricians and Gynaecologists
(RCOG) responded rapidly to develop an evolving guide-
line and information for women and their families on
the impact of COVID-19 in pregnancy [2, 3]. The find-
ings from the first study into outcomes of women af-
fected by COVID-19 in the UK showed that women
from a Black, Asian and Minority Ethnic (BAME) back-
ground were more likely to die from COVID-19 and also
at higher risk of developing complications of COVID-19
[4]. This study is designed to explore pregnant women’s
perceptions of COVID-19 and their healthcare experi-
ences. It is designed to obtain insight into any barriers
to healthcare during this pandemic and any concerns
women have about any stage of their pregnancy. It is
hoped that the voices of pregnant women from this
study will be used to shape future maternity services.
Methods
Ethical approval was obtained from the University of
East Anglia (reference 2019/20–06).
Design
A 26-item questionnaire (combination of open and
closed-ended questions) was developed by a team of cli-
nicians and academics through the guidance and support
of patient and public involvement. Five women who are
currently pregnant and five midwives of varying age,
clinical background and ethnicity were asked on their
feedback of the questionnaire with regards to the con-
tent and wording. The questionnaire aimed to explore
pregnant women’s perceptions of COVID-19, the impact
of it antenatally, intrapartum and post-partum through
free text questions. It was also designed to explore any
perceived barriers to care during this pandemic. Consen-
sus of the content of the questionnaire and its design
was determined as a group through discussion. The
questionnaire is available as a supplementary file.
Page 2 of 8
Data collection
The questionnaire on Survey Monkey was advertised on-
line between 1st May 2020- 9th May 2020 through the
BBC website, Twitter and other online spaces facilitated
by the research midwifery team. The local radio station
also advertised the study. The data was collected over 9
days from Survey Monkey and once the response rate
was above 1400, the questionnaire was deactivated as
saturation was deemed to have been reached. The ques-
tionnaire was available to anyone who was currently
pregnant or had delivered since the COVID-19 pan-
demic commended in the UK.
The data was collected and analysed daily and satur-
ation was defined as no new themes being generated
from the responses. We ensured that the questionnaire
was advertised through many different online groups
and through the BBC news website page to ensure we
reached a wide range of participants.
Analysis of data
The findings from the free text questions were analysed
by qualitative thematic analysis [5–7] and the findings
were contextualised to the clinical setting by all five au-
thors on a Microsoft Excel spreadsheet. Some questions
were analysed by simple percentages and presented in a
table. The open-ended questions were analysed by the-
matic analysis. Thematic analysis is used to analyse
opened-ended data (for example from a survey or inter-
view) to identify and generate patterns from within it
(called themes). This involved becoming familiar with the
data set (reading the responses and understanding them),
creating initial codes (attaching labels to different sections
of the text), generating themes based on the respective
codes (by grouping different codes together) and applying
this to the context of our study question [7].
Results
In total 1552 individuals opened the questionnaire, but
1451 participants replied and completed the question-
naire. One thousand two hundred twenty-one partici-
pants were prenatal and 230 were postpartum. Table 1
shows the different participant demographics.
Other important information obtained from partici-
pants showed that 2% were diagnosed with COVID-19,
6% had a family member diagnosed with COVID-19 in
the same household and 58% were self-isolating due to
government advice and personal anxieties about ‘catch-
ing the virus’.
Identified themes
The main concerns and experiences discussed by partici-
pants were grouped under the categories of antenatal,
intrapartum and postpartum care. Before discussing
these themes, it is important to note why participants
Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600 Page 3 of 8

Table 1 To show the participant demographic data ‘Virtual consultations’; whilst participants understood
Demographic Proportion, n (%) why these measures were in place, 62% felt that this pro-
Age range vided ‘impersonal care’ and it affected how much infor-
18–24 37 (2.56)
mation they disclosed to their healthcare worker. Two
participants who had hearing impairments explained
25–34 964 (66.29)
that they ‘could not communicate properly on the video
35–44 447 (30.89) link’ due to internet connectivity problems. Fourteen
45–54 3 (0.20) percent of participants explained that they were reluc-
Geographical location tant to speak about mental health issues over the phone.
East of England 266 (18.33) One participant explained that she did not want to dis-
East Midlands 80 (5.54)
close this information to her partner but isolating to-
gether made this difficult if asked about on the phone.
London 235 (16.27)
Eleven percent of participants said that they felt ‘embar-
North East 42 (2.91) rassed to talk about mental health concerns over the
North West 100 (6.93) phone’ and felt discussing sensitive issues over the tele-
Northern Ireland 24 (1.66) phone was not appropriate. Participants were worried
Scotland 75 (5.19) that ‘things may not be picked up on the phone that they
South East 256 (17.73)
would normally in person’. Six percent of women had a
previous stillbirth, and therefore would have preferred to
South West 148 (10.25)
have a face to face consultation to reduce anxiety.
Wales 56 (3.88) Twelve percent explained that they would have liked
West Midlands 84 (5.82) more written information about their care. Some partici-
Yorkshire And the Humber 85 (5.88) pants resorted to the internet for further advice. A num-
Ethnicity ber of participants explained that their mental health
White/White British 1334 (91.9)
related appointments were cancelled and felt that the
level of support was significantly reduced.
Black/Black British 10 (0.68)
A change in the way maternity services are accessed
Asian/Asian British 50 (3.44) has meant women have had to travel to different loca-
Mixed race 33 (2.27) tions for their care, and as such, public transport issues
Rather not say 4 (0.27) have made travelling a problem. Two percent of partici-
Other 20 (1.37) pants explained they were less mobile (due to wheelchair
Highest level of education
use) and therefore had problems accessing different de-
partments in the hospital when attending for appoint-
Less than secondary school qualifications 4 (0.28)
ments. The different ‘zoned areas based on ‘COVID
Secondary school qualification 163 (15) wards’ and ‘non-COVID wards’ made it difficult for
Some university, but no degree 72 (4.98) these people to access the correct areas in the hospital
Foundation degree 43 (2.97) and caused confusion. This was ‘made worse as partners
Bachelor’s degree 621 (42.95) were not allowed to attend’. Twenty-one percent of par-
Post-graduate degree 548 (37.9)
ticipants perceived that healthcare workers were ‘more
concerned about COVID-19′ than pregnancy related is-
sues itself.
sought maternity care during COVID-19. Seventy-three Twenty-eight percent of women explained that they
percent of the cohort sought medical or midwifery help were having ‘regular scans’ for a maternal or fetal reason,
during COVID-19 lockdown. Figure 1 shows the main however, due to COVID-19, the scan frequency had
reasons as to why participants contacted maternity triage changed, and was often reduced; women wanted more
during COVID-19. information about how this could impact their preg-
nancy. Twelve percent of women ‘avoided the hospital at
all costs’ and therefore did not attend for their routine
Below is a summary of the concern’s participants scan appointments due to concerns about contracting
expressed about their antenatal, intrapartum and COVID-19.
postnatal care Some participants explained that their booking ap-
Antenatal care pointment did not feel ‘detailed’ and were concerned
Participants provided insight into the following concerns that some aspects of their care may have been missed.
about their antenatal care (Fig. 2): They were also concerned as the doctor did not have
Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600 Page 4 of 8

Fig. 1 Chart to show the main reasons for contacting maternity triage during Covid-19

Fig. 2 Chart to show the main antenatal concerns expressed by participants

Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600
access to their full maternity records when conducting
the appointment virtually.
The media played a significant part in women’s per-
ception of hospitals and ‘risk of death’. Participants
recalled news articles on those who had unfortunately
died from COVID-19 and had concerns about either
dying themselves or their baby. Fourteen percent ex-
plained that should they be diagnosed with the virus,
then they were ‘worried about how healthcare workers
will treat them’ and were concerned as to whether staff
had the correct personal protective equipment. The use
of hospital services and the risk of asymptomatic trans-
mission from healthcare workers was also mentioned.
Importantly, two participants from Afro-Caribbean
backgrounds were told they were ‘more likely to die
from COVID-19’ but they were both unsure as to why.
Thirty-two percent explained they were worried about
the impact of the virus on medical co-morbidities such
as asthma and ‘not knowing where to go if symptoms of
asthma worsened’. Twelve percent provided insight into
the ‘conflict’ they experienced within themselves if
asthma symptoms were worsening and ‘whether to get
help or not’.
Over 60% of women sought help for reduced fetal
movements. They explained they felt reluctant in con-
tacting the hospital should they be asked to attend for
fetal monitoring. One woman described this as a ‘double
edged sword’ where she wanted to seek help for reduced
fetal movements, but yet, felt concerned about COVID-
19 exposure in hospital.
Some women with asthma raised concerns about its
symptoms being similar to COVID-19 and so wanted
more information on when to come to hospital should
symptoms worsen. Medical reasons for contact also in-
cluded pre-eclampsia, gestational diabetes, urinary tract
infection, vaginal bleeding, pelvic pain, mastitis, chicken-
pox exposure and ruptured membranes.
Twelve percent felt that their questions were ‘irrele-
vant’ in the current COVID-19 pandemic and therefore
felt ‘embarrassed’ to seek support. Some women ex-
plained that they perceived the ‘threshold for seeking
help had gone up during COVID-19’ and felt reluctant
to seek further help. Eighteen percent of women said
that they thought their concerns were not ‘serious
enough’ and thought that healthcare workers were only
dealing with ‘the seriously unwell’ patients or those with
COVID-19.
Intrapartum care
Participants provided insight into the following concerns
about their antenatal care (Fig. 3):
Partner presence was the most common theme dis-
cussed for intrapartum care. Participants explained that
they were worried about partners not being allowed to
Page 5 of 8
be present at all during labour or during active labour
only. They were also worried about ‘being alone’ should
there be an intrapartum problem.
The risk of ‘catching COVID-19’ was not surprisingly,
a common theme discussed. Participants were con-
cerned about ‘transmitting COVID-19 to the baby’ due
to recent news articles and online press.
Some participants expressed concerns about not being
able to ‘have a normal delivery’ and the ‘risk of a C-
Section’ if diagnosed positive for COVID-19. Eleven per-
cent discussed their concerns about ‘being separated
from the baby at delivery’ if COVID-19 was confirmed,
and ‘how they would be cared for by staff’ They also
expressed concerns related to the ‘stigma of being diag-
nosed’ and whether staff would feel comfortable looking
after them.
The majority of participants highlighted concerns
about the availability of a birthing pool and any restric-
tions on its use. Eleven percent of women felt they were
‘denied’ the opportunity to deliver in a birthing pool due
to COVID-19. In addition, concerns were raised as to
whether induction of labour would be cancelled or sig-
nificantly delayed. Participants were worried about stay-
ing on the ward in a bay with other patients who may be
asymptomatic of COVID-19. A number of women were
concerned about a hospital delivery and therefore
enquired about homebirth options.
Forty-two percent of women said that they did not
want to seek support as they were ‘worried about being
invited into hospital for a review’ and the risk of corona-
virus transmission. These concerns stemmed from the
governments advice to ‘Protect the NHS’, media reports
on the lack of personal and protective equipment (PPE)
for healthcare workers, the risk of contracting COVID-
19, fear of attending alone and waiting in a bay or room
with other patients. Participants explained that whilst
they were happy to attend the hospital if required as an
emergency or routine care, they felt unclear about any
specific precautions that they should take prior to at-
tending; ‘should I be wearing a face mask? Do I buy my
own face mask? Or will I be given one upon arrival to
the hospital?’
Two participants with a hearing impairment were con-
cerned about staff communicating with them during
labour with a protective mask on.
Postnatal care
Breastfeeding support was the most common theme
discussed as participants were concerned about how
these services will operate postnatally. Participants also
expressed significant concern about the reduced midwife
and health visitor contacts in the community. Some par-
ticipants explained thy were worried about postnatal de-
pression and were unsure where to seek support from.
Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600
Fig. 3 Chart to show the main intrapartum concerns expressed by participants
Women explained that social isolation based on gov-
ernment advice resulted in either a complete lack of sup-
port from family and friends, or a significant reduction
in support. A number of participants explained the
struggles they have faced post-delivery and the lack of
support from family members. The lack of wider support
from physiotherapy and allied health professionals in the
community has meant women have had to ‘find other
ways of coping’ 12% explained the challenges they
faced when seeking support from the General Prac-
tioner in terms of access to prescriptions and face to
face appointments. Three percent of participants
mentioned feeling ‘confused by what support the
pharmacist is now able to offer. Two percent of par-
ticipants were ‘unable to access dental care’ in terms
of emergency treatment or routine care.
Discussion
Main findings
The COVID-19 pandemic has been an unusual situation
and its impact on expectant and new mothers has been
significant. One thousand four hundred fifty-one partici-
pants replied to this questionnaire. The findings from
Page 6 of 8
this study provide significant insight into women’s per-
ceptions of COVID-19 and their healthcare experiences.
There is a significant amount of information on the con-
cern’s women have during their antenatal, intrapartum
and postnatal period. Whilst the study has yielded many
findings, the main areas of concern focussed around cor-
onavirus transmission, the use of virtual clinics ante-
natally and their acceptability to patients, the presence
of a birthing partner, and the way in which information
is communicated about rapidly changing and evolving
services. Fifty-nine percent of participants felt there were
barriers to accessing healthcare for pregnant women
during COVID-19 lockdown and discussed a multitude
of reasons. These included the use of virtual consulta-
tions, reluctance to discuss mental health issues virtually,
the perceived threshold for seeking help, the risk of cor-
onavirus transmission, the role of the media and changes
in the way services are delivered. The media appear to
have shaped some participants perceptions about hospi-
tals and their risk of ‘catching Corona’; subsequently,
this has had an impact on health seeking behaviour as
some participants felt ‘too worried’ to obtain medical or
midwifery help. Those participants who lived in a rural
Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600
location or coastal location were also less likely to seek
help due to barriers in physically accessing healthcare.
Whilst the number of participants from BAME back-
grounds was only 6%, the information they provided in
terms of barriers to health in particular was striking.
They explained the perceived ‘stigma’ they experienced
when seeking medical or midwifery experience. For one
reason or another, this group of participants detailed
negative experiences with healthcare workers and felt
they were ‘not taken seriously’. The use of PPE by
healthcare workers resulted in some participants experi-
encing ‘communication barriers’; this was particularly
discussed by those with hearing impairments.
Strengths and limitations
This is the first ever reported study in the United King-
dom to explore pregnant women’s perceptions of
COVID-19 and their subsequent healthcare experiences.
A significant number of changes have occurred in ma-
ternity care since the pandemic, and this study has shed
light onto what women perceive their care to be like at
this time. It has also provided insight into perceived bar-
riers into seeking care as well as maternal concerns ante-
natally, intrapartum and postpartum.
As this study was conducted online and as a survey,
researchers were not able to ask further questions to
clarify the responses. Whilst this was a national survey,
the vast majority of responses were from participants
who were white British and therefore, the results may
have been different if more individuals from Black, Asian
and Ethnic minority (BAME) groups replied. Whilst it is
difficult to quantify the exact number of participants
who may have been able to respond to the question-
naire, it is important to note that there were 640,370 live
births in England and Wales in 2019 [8]. The survey
largely reached those who are engaged in current affairs
and with online access; therefore, resulting in responder
bias. However, this work has enabled us to develop a
qualitative study involving semi-structured telephone in-
terviews with pregnant participants from BAME back-
grounds specifically to explore the impact of COVID-19
in greater detail. This is in progress currently.
Implications of findings
Our findings show that the impact of COVID-19 has
been significant to participants using maternity services.
Participants with co-existing mental health problems
also appear to be feeling stigmatised through the lack of
support services available. Participants explained in great
detail the impact of not being allowed to bring a birthing
partner to the hospital or place of care had on them.
There does not appear to be strategies in place to sup-
port patients in the antenatal, intrapartum or postnatal
period.
Page 7 of 8
Participants discussed their reluctance to address men-
tal health concerns with healthcare workers during the
pandemic. Some participants discussed the challenges of
discussing mood related concerns over the telephone.
There is emerging evidence to suggest that pregnant
women are experiencing significant anxiety during the
pandemic [9–11]. Further local and national strategies
should be considered by policy makers to help further
support this group of women.
It is clear that women’s’ healthcare is affected during
any global healthcare emergency; with the most recent
to COVID-19 being Ebola and H1N1 infection [12, 13].
Maternity units across the United Kingdom have had to
significantly change the way they deliver their services to
patients in view of this pandemic. There appears to be
stark differences between different units in the way care
is delivered, and as expected, this is causing anxiety
amongst patients. Participants provided insight into the
use of social media and Facebook forums to compare
the type of care they have received.
Whilst maternity units have had to react acutely to
this pandemic, the findings from this study do raise
questions as to the way services can be delivered into
the future. There may well be more of a focus on virtual
clinics through the use of other communication
methods. However, this study provides strong evidence
that research into the safety and efficacy of these tech-
niques. It also highlights that it will be important to have
high levels of patient and public engagement when such
service changes are being considered. A recent national
survey of junior doctors in the United Kingdom has also
explored this from a healthcare worker perspective [14].
The latest UKOSS study [4] of more than 400 preg-
nant women hospitalised with COVID-19 found that
55% of pregnant women hospitalised were from a BAME
background. There is also increasing published evidence,
that pregnant women who are from a BAME back-
ground may experience health inequalities during preg-
nancy for a number of reasons and this needs to be
explored further [4]. Our study, that involved 6% of par-
ticipants from a BAME background (who are particularly
more likely to be affected with an adverse outcome in
pregnancy or the puerperium) shows they experienced
some form of challenge in seeking medical or midwifery
attention in pregnancy. Our study has provided the basis
for further research with participants from a BAME
background in the form of semi-structured interviews
individually or via focus groups.
Conclusion
In summary, the COVID-19 pandemic has had a signifi-
cant impact in the way healthcare is currently being de-
livered in the UK. Maternity services have undergone a
significant change. Whilst these changes may be
Karavadra et al. BMC Pregnancy and Childbirth (2020) 20:600 Page 8 of 8

temporary, they highlight significant questions as to how
services should be delivered in the future. It cannot be
assumed that the current way of service delivery is ne-
cessarily acceptable to patients, and it is important to in-
volve the voices of women and their families when
designing such services. We hope the findings from this
study will be used to shape future maternity services in-
clude the use of virtual antenatal care.
Abbreviation
BAME: Black, Asian Minority Ethnic
Acknowledgements
We thank all the women who participated in the study. We were extremely
grateful for the BBC to advertise our study on their website. The Norwich
Maternity Voices Partnership were also kind in advertising the questionnaire
via Twitter.
Authors’ contributions
BK conceived the idea, wrote the protocol, submitted the ethics approval form,
developed the questionnaire and primarily analysed the data. BK, AS, EPS, PDS
and EPM checked the protocol, ethics application and questionnaire, analysed
parts of the data and drafted the final manuscript for submission. All authors
have read and approved the manuscript.
Funding
No funding was required.
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8. COVID-19 related deaths in the UK: https://www.ons.gov.uk/
peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/
bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinjune2
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Availability of data and materials Publisher’s Note

The datasets used and/or analysed during the current study are available Springer Nature remains neutral with regard to jurisdictional claims in
from the corresponding author on reasonable request. published maps and institutional affiliations.

Ethics approval and consent to participate

Ethical approval was obtained from the University of East Anglia Faculty of
Medicine and Health Sciences Research Ethics Committee on 29th April
2020. Reference 2019/20–06. Participants read a consent statement online
prior to the questionnaire starting. Participants were asked to click ‘yes’ if
they were happy with the consent statement; the questionnaire would then
begin. The ethics committee approved this method of obtaining consent
online.

Consent for publication

Not applicable.

Competing interests
The authors declare that they have no competing interests.

Received: 11 June 2020 Accepted: 24 September 2020

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